915.pdf 915Vol. 10 | No. 2 | Spring 2013 |U R O LO G Y J O U R N A L Hair-Thread Tourniquet Syndrome in an Adult Penis Case Report and Review of Literature Sataa Sallami, Sami Ben Rhouma, Karim Cherif, Yassine Noura Keywords: penis, hair, tourniquets, complications, reconstructive surgical procedures INTRODUCTION Hair-thread tourniquet syndrome (HTTS) is an unusual entity occurring mainly in young age. It is due to a hair-strangulation of an appendage, such as the penis, caus-ing obstruction to circulation.(1) We report a new case in an adult patient. CASE REPORT A 37-year-old man presented to the urology outpatient’s clinic with a 10-year history of post- coital pain. He had no history of trauma, foreign body, or allergy. He has been circumcised 32 years before. Clinical examination revealed a constrictive ring scar at the distal penis (Figure 1). There was neither any change in the skin color or texture nor in sensation distal to the scar. He had mini- mal granulation tissue on the ventral aspect of the scar (Figure 2). There was a palpable dense - trolytes, and serum creatinine levels were normal. Findings on urinalysis were negative. He reported that in his childhood and during 3 years his mother used to put a hair around the distal part of his penis to increase his future sexual function. This hair had caused infection; thus, it was removed long time ago. Corresponding Author: Sataa Sallami, MD Department of Urology, La Rabta Hospital-University, Tunis, Tunisia Tel: + 216 2338 7359 Fax: + 216 7179 6602 E-mail: sataa_sallami@yahoo.fr Received April 2011 Accepted August 2011 Department of Urology, La Rabta Hospital-University, Tunis, Tunisia CASE REPORT 916 | Keywords: penis, hair, tourniquets, complications, recon- structive surgical procedures INTRODUCTION Hair-thread tourniquet syndrome (HTTS) is an unu-sual entity occurring mainly in young age. It is due to a hair-strangulation of an appendage, such as the penis, causes obstruction to circulation.(1) We report a new case in an adult patient. CASE REPORT A 37-year-old man presented to the urology outpatient’s clinic with a 10-year history of post-coital pain. He had no history of trauma, foreign body, or allergy. He has been cir- cumcised 32 years before. Clinical examination revealed a constrictive ring scar at the distal penis (Figure 1). There was neither any change in the skin color or texture nor in sensation distal to the scar. He had minimal granulation tissue on the ventral aspect of the scar below the scar. The bladder did not distend. His blood urea nitrogen, electrolytes, and serum creatinine levels were nor- mal. Findings on urinalysis were negative. He reported that in his childhood and during 3 years his mother used to put a hair around the distal part of his penis to increase his future sexual function. This hair had caused infection, thus it was removed long time ago. At surgery, under general anesthesia, the penile skin was dis- circumferentially excised. Fibrous tissue was excised and re- moved (Figure 3), and the cutaneous incision was repaired (Figures 4 and 5). Pre-operatively, the urethra was intact at inspection. The patient was discharged from the hospital on months. He has been voiding well with no sexual dysfunc- tion (Figure 6). DISCUSSION Hair coil strangulation of the penis, also known as the penile tourniquet syndrome, is a rare event.(1) It is a serious compli- cation, usually contested in North Africa.(2) It is considered as a circumferential constriction of an appendage (digit or Case Report Figures 1 and 2. The ring scar (circumferential fibrosis) on the penis (coronal sulcus) (arrow) and the exuberant granulation on the ventral aspect. Figure 3. Specimen: ring-shaped excised skin. 917Vol. 10 | No. 2 | Spring 2013 |U R O LO G Y J O U R N A L Hair-Thread Tourniquet Syndrome in Adults | Sallami et al genitalia) by human hairs or occasionally a piece of thread or (3) Hair remains the most common causative agent. Its physical characteristics make it an ideal tourniquet. It is thin, elastic, and expansible when wet, but constricts as it dries off without losing its strength.(4) According to Mat Saad and colleagues who reviewed a to- tal of 210 reported HTTS, penile involvement occurred in - nile tourniquet was more common in patients around 2 years old.(4) The oldest reported subject was 12 years.(2) Hair-thread tourniquet syndrome in young age is presumed to be accidental.(5-7) However, Barton and colleagues re- ported a case of criminal abuse.(3) In the present case, the reason why this patient had the hair around his penis was not immediately apparent. This backs-up to his childhood, based on popular believes to increase sexual capability. The penile strangulation etiologies have been divided by Haddad into accidental, incidental, intentional, and undetermined causes. The circumcision has been considered to be a major risk fac- tor of strangulation; the hair or other agents seem to constrict more easily a circumcised penis than one with a normal pre- puce.(8) Compression of the penis will cause blood and lym- on the force and duration of the compression.(9) are often delayed. Swelling, erythema, circumferential con- striction, and distal oedema resume the early clinical presen-Figures 4 and 5. Operative and immediate postoperative aspect. Figure 6. Postoperative aspect after 2 months. 918 | Case Report 4. Mat Saad AZ, Purcell EM, McCann JJ. Hair-thread tour- niquet syndrome in an infant with bony erosion: a case report, literature review, and meta-analysis. Ann Plast Surg. 2006;57:447-52. 5. Miller RR, Baker WE, Brandeis GH. Hair-thread tourniquet syndrome in a cognitively impaired nursing home resident. Adv Skin Wound Care. 2004;17:351-2. 6. Vazquez Rueda F, Nunez Nunez R, Gomez Meleno P, Blesa Sanchez E. [The hair-thread tourniquet syndrome of the toes and penis]. An Esp Pediatr. 1996;44:17-20. 7. Thomas AJ, Jr., Timmons JW, Perlmutter AD. Progressive penile amputation. Tourniquet injury secondary to hair. Urology. 1977;9:42-4. 8. Haddad FS. Penile strangulation by human hair. Re- port of three cases and review of the literature. Urol Int. 1982;37:375-88. 9. De Silva-Gutiérrez A, Osorio-Campos J, Arcos-Marcín M, Morales-Díaz J, Martínez-Méndez M. Glans autoamputa- tion secondary to penile strangulation causing ischemic necrosis. Rev Mex Urol. 2008;68:341-3. 10. Singh B, Kim H, Wax SH. Strangulation of glans penis by hair. Urology. 1978;11:170-2. 11. Jezior JR, Brady JD, Schlossberg SM. Management of penile amputation injuries. World J Surg. 2001;25:1602-9. 12. Nazir Z, Rasheed K, Moazam F. Penile constrictive band injury. J Pak Med Assoc. 1993;43:135-7. 13. Harouchi A, El-Andaloussi ME, Benhayoun N. [Les strangu- lations du gland par cheveu]. Inf Magh Medical. 1980;2:19- 26. 14. Okeke LI. Thread embedded into penile tissue over time as an unusual hair thread tourniquet injury to the penis: a case report. J Med Case Rep. 2008;2:230. tation.(6) Early recognition and removal are usually followed by complete recovery. If the tourniquet is not removed early, there may be progression to skin infection and ulceration. Therefore, it is of utmost importance for the physician to act quickly in order to prevent irreversible damage and necrosis of the penis.(9) When diagnosed very late, the dorsal neurovascular bun- dle may be transected, leading to the loss of sensation over the distal part of the penis with a high risk of partial or total amputation of the penis distal to the tourniquet.(10-12) Four grades of injury were described by Harouchi and associ- ates,(13) the loss of the glans (Grade IV). An unexplained pain and swelling of the penis should sus- pect this rare entity.(1) In our patient, there were no ischemic skin changes, no loss of sensation over the glans penis, and tourniquet was not too tightly applied. The ischemia might be partial and chronic, thus causing minimal tissue damage.(14) limited to the skin and did not reach the urethra. Hair-thread tourniquet syndrome of the penis in adult is a very rare and poorly recognized condition that needs to be known. Early diagnosis and rapid and adequate treatment can prevent from serious complications. Non-accidental causes should be considered carefully in these subjects. Further- more, patient's history should be taken very carefully with meticulous enquiry on popular believes and practices in the society he originates from. CONFLICT OF INTEREST None declared. REFERENCES 1. Silver RI, Docimo SG. Hair coil strangulation of the penis. Urology. 1997;49:773. 2. Mhiri MN, Midassi H, Mezghanni M, Smida ML. [Strangula- tion of glans penis by hair or "penis tourniquet syndrome"]. Pediatrie. 1987;42:351-3. 3. Barton DJ, Sloan GM, Nichter LS, Reinisch JF. Hair-thread tourniquet syndrome. Pediatrics. 1988;82:925-8.